Acute pancreatitis

Last reviewed: January 20, 2010.

Acute pancreatitis is sudden swelling and inflammation of the pancreas.

Causes, incidence, and risk factors

The pancreas is an organ located behind the stomach that produces chemicals called enzymes, as well as the hormones insulin andglucagon. Most of the time, the enzymes are only active after they reach the small intestine, where they are needed to digest food. When these enzymes somehow become active inside the pancreas, they eat (and digest) the tissue of the pancreas. This causes swelling, bleeding (hemorrhage), and damage to the pancreas and its blood vessels. Acute pancreatitis affects men more often than women. Certain diseases, surgeries, and habits make you more likely to develop this condition. The condition is most often caused by alcoholism and alcohol abuse (70% of cases in the United States). Genetics may be a factor in some cases. Sometimes the cause is not known, however. Other conditions that have been linked to pancreatitis are: y y y y y Autoimmune problems (when the immune system attacks the body) Blockage of the pancreatic duct or common bile duct, the tubes that drain enzymes from the pancreas Damage to the ducts or pancreas during surgery High blood levels of a fat called triglycerides (hypertriglyceridemia) Injury to the pancreas from an accident

Other causes include: y y y y y y y Complications of cystic fibrosis Hemolytic uremic syndrome Hyperparathyroidism Kawasaki disease Reye syndrome Use of certain medications (especially estrogens, corticosteroids, thiazide diuretics, and azathioprine) Viral infections, including mumps, coxsackie B, mycoplasma pneumonia, and campylobacter

Symptoms
The main symptom of pancreatitis is abdominal pain felt in the upper left side or middle of the abdomen. The pain: y y y y May be worse within minutes after eating or drinking at first, especially if foods have a high fat content Becomes constant and more severe, lasting for several days May be worse when lying flat on the back May spread (radiate) to the back or below the left shoulder blade

People with acute pancreatitis often look ill and have a fever, nausea, vomiting, and sweating. Other symptoms that may occur with this disease include:

y y y y y y y

Clay-colored stools Gaseous abdominal fullness Hiccups Indigestion Mild yellowing of the skin and whites of the eyes (jaundice) Skin rash or sore (lesion) Swollen abdomen

Signs and tests

The doctor will perform a physical exam, which may show that you have: y y y y y Abdominal tenderness or lump (mass) Fever Low blood pressure Rapid heart rate Rapid breathing (respiratory) rate

Laboratory tests will be done. Tests that show the release of pancreatic enzymes include: y y y Increased blood amylase level Increased serum blood lipase level Increase urine amylase level

Other blood tests that can help diagnose pancreatitis or its complications include: y y Complete blood count (CBC) Comprehensive metabolic panel

Imaging tests that can show inflammation of the pancreas include: y y y Abdominal CT scan Abdominal MRI Abdominal ultrasound

Treatment
Treatment often requires a stay in the hospital and may involve: y y y Pain medicines Fluids given through a vein (IV) Stopping food or fluid by mouth to limit the activity of the pancreas

Occasionally a tube will be inserted through the nose or mouth to remove the contents of the stomach (nasogastric suctioning). This may be done if vomiting or severe pain do not improve, or if a paralyzed bowel (paralytic ileus) develops. The tube will stay in for 1 - 2 days to 1 - 2 weeks. Treating the condition that caused the problem can prevent repeated attacks. In some cases, therapy is needed to:

y y y

Drain fluid that has collected in or around the pancreas Remove gallstones Relieve blockages of the pancreatic duct

In the most severe cases, surgery is needed to remove dead or infected pancreatic tissue. Avoid smoking, alcoholic drinks, and fatty foods after the attack has improved.

Expectations (prognosis)
Most cases go away in a week. However, some cases develop into a life-threatening illness. The death rate is high with: y y y Hemorrhagic pancreatitis Liver, heart, or kidney impairment Necrotizing pancreatitis

Pancreatitis can return. The likelihood of it returning depends on the cause, and how successfully it can be treated.

Complications
y y y y y y Acute kidney failure Acute respiratory distress syndrome (ARDS) Buildup of fluid in the abdomen (ascites) Cysts or abscesses in the pancreas Heart failure Low blood pressure

Repeat episodes of acute pancreatitis can lead to chronic pancreatitis.

Calling your health care provider

Call your health care provider if: y y You have intense, constant abdominal pain You develop other symptoms of acute pancreatitis

Prevention
You may lower your risk of new or repeat episodes of pancreatitis by taking steps to prevent the medical conditions that can lead to the disease: y Avoid aspirin when treating a fever in children, especially if they may have a viral illness, to reduce the risk of Reye syndrome. Do NOT drink too much alcohol. Make sure children receive vaccines to protect them against mumps and other childhood illnesses (see: Immunizations - general overview).

y y

What is pancreatic necrosis?

Severe pancreatitis causes death of parts of the pancreas. The injured and dying pancreas releases digestive enzymes in the pancreas, which causes extensive death of fatty tissue in the abdomen. As a consequence patients with severe pancreatitis have dead pancreatic tissue and also widespread death of fatty tissue around the pancreas.This dead pancreas tissue is called pancreatic necrosis and the dead fatty around the pancreas is called peripancreatic necrosis.

What happens to pancreatic necrosis?

In patients with severe pancreatitis, careful observation leads to improvement without an operation in about 60 to 70 percent of people. Thirty percent of patients will develop either progressive deterioration or infection in their necrosis and require surgery. The necrotic tissue is susceptible to infection and infections are very common in patients with severe pancreatitis.

Sterile and infected necrosis

When the dead pancreas is not infected, it is called sterile necrosis. When the dead pancreas is infected then it is called infected necrosis. More than 80% of deaths amongst patients with acute pancreatitis are caused by infection of the dead pancreatic tissue.The treatment of sterile and infected necrosis is complex and the patient may benefit from treatment in a specialty center that treat a high volume of these conditions.

Sterile Necrosis
Patients with sterile necrosis have dead pancreatic tissue, however there is no infection of the dead tissue. The recommended treatment for this group of patients is close observation in the hospital. Patients are placed on intravenous feeding and undergo serial examination with CT scans for early detection of infection. We would consider surgery in patients with sterile necrosis under the following circumstances     Patients who fail to improve after about two to three weeks after the onset of their pancreatitis and continue to complain of severe in the abdomen. If there is concern that there might be infection in the necrosis Patients who continue to be critically ill after two weeks and require continued pulmonary and cardiac support Patients whose condition appears not be improving and or continue to deteriorate based on various measurements

When is surgery done in patients with sterile necrosis The timing of surgery has been controversial. At USC our preference is to wait for about two weeks after onset of pancreatitis for surgery for sterile necrosis, as long as the patient does not have signs and symptoms of severe infection. The longer the wait the better the chance that the patient will have an adequate debridement (see below underSurgery for acute pancreatitis).

Usually after two weeks the dead pancreas tissue is demarcated (separated) from the live tissue and can be easily removed. Early surgery often leads to inadequate debridement of the necrosis since the demarcation has not occurred. Surgery for sterile necrosis is preferentially performed by laparoscopic techniques at our Center.

Infected Necrosis
Infected necrosis occurs in patients who develop infection in areas of pancreatic and peripancreatic necrosis. This is a severe complication and requires aggressive treatment. More than 80% of deaths amongst patients with acute pancreatitis are caused by infection of the dead pancreatic tissue. Without aggressive surgical treatment to clear the infection, many patients do not survive the infection. Multiple surgeries may be required to completely clear the infection. Patients with infected necrosis require emergent surgery. The treatment of infected necrosis is complex and these critically ill patients may benefit from treatment in a specialty center that treat a high volume of these conditions.

Surgery for acute pancreatitis

The surgery that is performed remove all the dead pancreas is called debridement of pancreatic necrosis. The term debridement means removal of all dead or necrotic tissue. In this surgery all dead or necrotic pancreas and any dead tissue outside of the pancreas is removed. Dead fatty tissue outside of the pancreas occurs in areas around the stomach and around the kidneys and sometimes the dead fat tissue may be found in the lower abdomen. The CT scan is very useful for planning surgery and all areas identified on CT scan of having necrotic or dead tissue are opened up and the dead areas are removed.

Laparoscopic Pancreatic Debridement

We have developed a specialized laparoscopic procedure for pancreatic debridement. In this procedure two to three small incisions are utilized for placements of laparoscopic instruments and a two-inch incision is utilized for placement of a hand-access device into the abdomen. The necrotic tissue in and the pancreas is accessed and completely removed. In addition to that, the necrotic tissue in other areas such as around the kidneys, colon, and pelvis may also be removed through laparoscopic techniques. In our hands laparoscopic removal of the dead and necrotic pancreas is now the procedure of choice and open surgery is performed only in patients where at the time of the laparoscopic procedure we have concern that complete debridement has not been performed.

Long term outcome after surgical treatment for pancreatic necrosis

Many patients often require multiple surgeries to remove all the necrotic tissue. Patients often remain critically ill for a long period after their surgery until the infection subsides. The long-term complications after surgical treatment of acute pancreatitis are the following:  Pancreatic Fistula: A pancreatic fistula is leakage of pancreatic juice in the abdomen from an injury to the pancreas. The majority of patients develop a

 

pancreatic fistula after surgery. The fistula is from areas of raw surfaces on the pancreas left behind after removal of the entire dead pancreas. In the vast majority of patients, the fistula heals without any further surgery; however in some patients additional surgery may be required to remove the part of the pancreas that is contributing to the fistula. Pancreatic Pseudocyst Diabetes: Many patients develop diabetes after a severe attack of acute pancreatitis. Often the diabetes improves over time; however, some patients may have permanent diabetes if a large amount of the pancreas has been destroyed by the pancreatitis Chronic Pancreatitis

Manufacturer Distributor Contents Indications

Medbase Pharma Medbase Pharma Clopidogrel Prevention of atherosclerotic events in peripheral arterial disease, w/in 35 days of MI, w/in 6 mth of ischemic stroke or (given w/ aspirin) in acute coronary syndrome w/out ST-segment elevation. Recent MI, stroke or established peripheral arterial disease: 75 mg once daily. Acute coronary syndrome (unstable angina/non-Q wave MI) Initially 300-mg loading dose, continued at 75 mg once daily, w/ 75-325 mg aspirin daily. May be taken with or without food Patients at risk of increased bleeding from trauma, surgery or other pathological conditions. Patients w/ ulcer, severe hepatic & renal impairment. Pregnancy & lactation. Childn. Neutropenia/agranulocytosis, abdominal pain, dyspepsia, gastritis, constipation, diarrhea, skin rash & pruritus View ADR Monitoring Form NSAIDs, warfarin. View more drug interactions with Clovax

Dosage

Administration Special Precautions Adverse Drug Reactions Drug Interactions Pregnancy Category (US FDA)

Contraindications Peptic ulcer or intracranial hemorrhage.

Category B: Either animal-reproduction studies have not demonstrated a foetal risk but there are no controlled studies in pregnant women or animalreproduction studies have shown an adverse effect (other than a decrease in fertility) that was not confirmed in controlled studies in women in the 1st trimester (and there is no evidence of a risk in later trimesters). Anticoagulants, Antiplatelets & Fibrinolytics (Thrombolytics)

MIMS Class

ATC Classification Poison Schedule [?]

B01AC04 - Clopidogrel ; Belongs to the class of platelet aggregation inhibitors excluding heparin. Used in the treatment of thrombosis. Rx